Citation Nr: 21008854 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 15-19 490 DATE: February 18, 2021 ORDER A rating in excess of 10 percent for painful motion of the right knee is denied. For the appeal period prior to January 22, 2016, a separate 10 percent rating, but no higher, for slight instability of the right knee is granted. For the appeal period beginning January 22, 2016, a rating in excess of 10 percent for instability of the right knee is denied. For the entire rating period on appeal, a separate 20 percent rating, but no higher, for dislocation of the semilunar cartilage of the right knee is granted. FINDINGS OF FACT 1. Throughout the relevant appeal period, range of motion in the right knee has most closely approximated normal motion (zero degrees extension to 140 degrees flexion) with painful motion. 2. For the entire rating period on appeal, the Veteran’s right knee disability has been manifested by slight instability; the evidence is against a finding of moderate instability or a finding that a medical provider has prescribed the use of an assistive device (such as a brace, cane, or walker) for bracing for ambulation. 3. The evidence is at least evenly balanced as to whether the Veteran’s service-connected right knee disability involves dislocation of the semilunar cartilage with frequent episodes of “locking”, pain, and effusion into the joint. CONCLUSIONS OF LAW 1. The criteria for an evaluation higher than 10 percent for limited flexion of the right knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DCs) 5260, 5261 (2020). 2. For the appeal period prior to January 22, 2016, the criteria for a separate 10 percent disability rating, but no higher, for slight instability of the right knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71a, DC 5257 (2020); 85 Fed. Reg. 76,453, 76,463 (November 30, 2020). 3. For the appeal period beginning January 22, 2016, the criteria for a rating in excess of 10 percent for instability of the right knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71a, DC 5257 (2020); 85 Fed. Reg. 76,453, 76,463 (November 30, 2020). 4. For the entire rating period on appeal, the criteria for a separate 20 percent disability rating, but no higher, for dislocation of the semilunar cartilage of the right knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71a, DC 5258 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1999 to July 2001. This case comes to the Board from a June 2014 decision of the Agency of Original Jurisdiction (AOJ) which denied an increase in the previously assigned 10 percent rating for a service-connected right knee disability, described as medial femoral condyle status post arthroscopic surgery. The Veteran appealed the denial of a higher rating. The Board remanded this case for further development in December 2018 and, most recently in April 2020. After the most recent remand, the AOJ issued a decision granting a separate rating of 10 percent for instability of the right knee under 38 C.F.R. § 4.71a, Diagnostic Code 5257, with an effective date of January 22, 2016. Because the regulation potentially authorizes higher ratings for the knee disability and the Veteran has not expressed satisfaction with the amount of this increase, his claim for an increased rating remains on appeal. See A.B. v. Brown, 6 Vet. App. 35, 38 (1993). Rating Criteria Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Staged ratings or the assignment of different disability evaluations for separate periods of time may be appropriate when the claimant has appealed the denial of a request for an increase in the rating previously assigned to a service-connected disability. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Under 38 C.F.R. § 4.40, DeLuca v. Brown, 8 Vet. App. 202, 206 (1995) and Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011), when evaluating the severity of certain disabilities, including disabilities of the knees, VA is generally required to consider whether the disability resulted in a level of functional loss greater than that already contemplated by the assigned rating. Relevant factors include weakness, fatigability, lack of coordination, restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. Whenever possible, VA examiners assessing the nature of additional functional loss should describe any additional functional limitations, if possible, in terms of additional degrees of range of motion loss. See Mitchell, 25 Vet. App. at 33. VA examination reports for musculoskeletal disabilities must comply with 38 C.F.R. § 4.59 by evaluating range of motion in the affected joint “for pain on both active and passive motion and in weight bearing and nonweight-bearing....” Correia v. McDonald, 28 Vet. App. 158, 170 (2016). VA examiners also have the duty to elicit information from the Veteran describing the condition of the relevant joints after repeated use over time and during “flare-ups” or episodes when the relevant symptoms are at their worst. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). A Veteran with a service-connected knee disability may receive separate disability ratings for limited flexion, limited extension, instability, and for dislocation or removal of the meniscus or semilunar cartilage. See Lyles v. Shulkin, 29 Vet. App. 107, 109 (2017); VAOPGCPREC 9-98; VAOPGCPREC 9-2004. 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5260 (“Leg, limitation of flexion of”) indicates that a noncompensable (zero percent) rating is appropriate when flexion is limited to 60 degrees. A 10 percent rating is appropriate if flexion is limited to 45 degrees and higher ratings of 20 or 30 percent are authorized if flexion of the knee is limited 30 or 15 degrees, respectively. DC 5261 (“Leg limitation of extension of”) authorizes a noncompensable (zero percent) rating if extension is limited to 5 degrees. A 10 percent rating is appropriate when extension is limited to 10 degrees. DC 5261 authorizes progressively higher ratings corresponding to more severe levels of limited extension, the maximum being a 50 percent rating when extension is limited to 45 degrees. The AOJ assigned the Veteran a 10 percent rating for the right knee pursuant to the provision of 38 C.F.R. § 4.59, recognizing “actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint.” The minimum compensable rating authorized by this regulation is appropriate when there is pain or painful motion in the relevant joint, even if the joint is not actually limited or, if motion is limited, when motion is not limited to the extent required for a compensable rating by the relevant diagnostic code based on limited motion. See Petitti v McDonald, 27 Vet. App. 415, 425-26 (2015); Mitchell, 25 Vet. App. at 34. VA recently amended the criteria for rating knee instability. 85 Fed. Reg. 76,453, 76,463 (November 30, 2020). These amendments apply only to claims pending as of February 7, 2021. Because the Veteran’s increased rating claim was pending on that date, the Board will consider both versions and, for the period since the effective date of the amendment, apply the criteria most favorable to the Veteran. See Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). But the Board may not apply the amended version of regulation prior to its effective date. See Kuzma v. Principi, 341 F.3d 1327, 1328-29 (Fed. Cir. 2003). The version of DC 5257 in effect until very recently (February 7, 2021) authorized a 10 percent rating for recurrent subluxation or lateral instability which is “slight”, a 20 percent rating if it is “moderate”, or a 30 percent rating for “severe” recurrent subluxation or lateral instability. The amended version of DC 5257 is much more specific, with different criteria for patellar instability and for recurrent subluxation or instability. Under the new criteria, recurrent subluxation or instability involves either sprain, incomplete ligament tear, or complete ligament tear (whether repaired, unrepaired, or failed repair), and the impairment must result in persistent instability of the affected knee. For a 10 percent rating, there is no need for a prescribed brace or assistive device, such as a cane, crutch, or walker, but a prescription from a medical provider is required for the 20 and 30 percent ratings. The difference between the 20 and 30 percent ratings is that, for a 20 percent rating, the prescription need only be for either a brace or an assistive device. For a 30 percent rating, the prescription must be for both and the disability must be an unrepaired or failed repair of a complete ligament tear. Patellar instability is defined as a diagnosed condition involving the patellofemoral complex and must result in recurrent instability. Note (1) to the new criteria define the patellofemoral complex as “the quadriceps tendon, the patella, and the patellar tendon.” 85 Fed. Reg. at 76,463. For patellar instability, new DC 5257 likewise authorizes 10, 20, and 30 percent ratings, differentiated by the type of impairment and whether a medical provider has prescribed a brace or assistive device. A 10 percent rating does not require a history of surgical repair or a prescribed brace, cane, or walker. A 20 percent rating requires surgical repair and a prescription for either a brace, cane, or walker, while a 30 percent rating requires surgical repair and a prescription for a brace and either a cane or a walker. A second note to this section clarifies that the surgery contemplated by the patellar instability criteria is specifically to repair one or more patellofemoral components; the note disqualifies arthroscopy to remove loose bodies and joint aspiration as surgical repair for patellar instability. Id. Factual Background To help decide the Veteran’s claim for an increased rating, the AOJ arranged for a physician to examine his knee in October 2014. According to the examiner’s report, the diagnoses were meniscus tear and a defect of the medial femoral condyle, status post arthroscopy. During initial testing, motion of the right knee ranged from zero degrees extension (normal) to 135 degrees flexion (140 degrees is normal). According to the examiner, objective evidence of painful motion began with flexion of 125 degrees. The right knee was capable of repetitive use testing, and there were no further limits on motion after three repetitions. After the examiner asked him about his symptoms during flare-ups, the Veteran, “describe[d] the impact as increased pain and stiffness. The knee will catch and feel “unstable.” Following that there can be swelling. The swelling has been fairly constant and he takes Aleve daily.” The examiner also administered tests of muscle strength and joint stability. For the right knee, muscle strength was normal (5/5). The results of anterior, posterior and medial-lateral instability tests were normal. According to the examiner, there was no evidence or history of patellar subluxation/discoloration. The examiner indicated that a meniscus (semilunar cartilage) condition of the right knee was present, with frequent episodes of joint “locking”, joint pain, and joint effusion. In response to language on the examination questionnaire asking if the Veteran had any residual signs and/or symptoms of meniscectomy, the examiner wrote, “The claimant reports that he has had increasing pain, stiffness, locking and difficulty with climbing steps and ladders” The examiner also reviewed imaging studies from the time of the initial in-service knee injury in 1999 and the notes concerning its subsequent surgical repair. The examiner wrote that, “While the operative note indicated only superficial fissuring of the surface [of the femoral condyle] it is possible that it caused some subsurface detachment of the articular cartilage.” In the “remarks” section of the report, the examiner noted pain, stiffness, and swelling and suggested an MRI study and consultation with an orthopedic surgeon. The claims file includes several medical records concerning the right knee between the dates of the first and second VA examination reports during the relevant appeal period. As suggested by the first examiner, the Veteran had an MRI study and consulted an orthopedic surgeon in November 2014. The surgeon’s notes describe “good full range of motion from 0 to 135 degrees. His knee is stable to varus and valgus stress at 0 and 30 degrees. He has stable Lachman and posterior drawer. He has some tenderness anterior medially right next to the patellar tendon on the tibial joint line. He has no crepitus or grind. His patella tracks normally.” The surgeon reviewed the MRI study, which indicated “relatively well preserved cartilage with some mild thinning.” The records include the notes of a pain medicine specialist, dated April 2015, which indicate negative results for the anterior and posterior drawer tests for joint instability. The Veteran described knee pain as present daily: “aggravating factors include climbing stairs at work (also with squat exercises according to medical record review); relieving factors include ice, sleep and NSAIDs.” But he also reported that symptoms “improved under a supervised exercise program.” A June 2015 primary care physician’s note indicates normal range of motion in the knees. The Veteran consulted a rheumatologist in July 2015 and his notes observe that knee pain usually occurred after exercise. The Veteran complained of “mild popping” in both knees but he “[d]enies any instability.” According to the rheumatologist, range of motion was “full” with normal muscle strength. There was no effusion, swelling, or edema. In November 2015, the AOJ arranged another knee examination. According to the examiner’s report, the diagnoses were right knee meniscal tear and post traumatic arthritis of the right knee. Initial range of motion test results for the right knee were normal (zero degrees extension to 140 degrees flexion) and remained normal after repetitive use testing. According to the examiner, there was no pain with weight bearing, no objective evidence of crepitus, and no localized tenderness or pain to palpation of the joint or associated soft tissue. The examiner apparently asked the Veteran to describe flare-ups of his right knee symptoms and indicated he “[h]ad two flare-ups in the last 12 months that lasted 2-3 days which requires rest elevation and aleve.” The examination also included muscle strength and joint stability tests. Right knee muscle strength was normal (5/5) during both flexion and extension. The results of tests of anterior, posterior, medial, and lateral instability were all normal. According to the examiner, the Veteran did not have joint instability. The examiner indicated “yes” when asked if the Veteran ever had a meniscus or semilunar cartilage condition. When asked to indicate the severity and frequency of symptoms and to identify the side affected, the examiner indicated “Right Side: Meniscal tear Frequent Episodes of Joint Pain . . .” In response to the questionnaire’s request for estimates of range of motion after repeated use over time and during flare-ups, the examiner wrote that such estimates required speculation because the examiner was not present to observe the Veteran after repeated use over time or during a flare-up. Subsequent VA treatment records mostly repeat information described above. But a January 2016 primary care note described “worsening” of the Veteran’s right knee symptoms after he was “doing box jumps with sudden severe sharp pain and ‘pop’. . . Joints feel loose, especially on the medial aspect.” The physician noted a report of “mild subjective medial joint instability and [he] continues to have sharp pain going up or down stairs. He is trying to compete in cross fit games, he is very fit and active.” In March 2016, another MRI study indicated “no clear meniscus pathology but positive joint line tenderness and medial McMurry’s [test.]” In April 2018, through his representative, the Veteran submitted a statement indicating that his right knee disability had “gotten worse.” Another potential indicator of right knee instability is a September 2016 primary care note, which reports that the Veteran sought treatment when his knee “buckled”, causing an injury to his left ankle. However, a January 2018 primary care note indicated that there was no instability of the knee. The same note described intermittent pain in the right ankle and confirmed that “his knee giving out is what he reports caused his [left] ankle injury.” Another MRI report, dated February 2018, indicated that there was no evidence of meniscal injury, but there was a small, partially ruptured Baker’s cyst. A physical therapy note, also from February 2018, indicates that the right knee remained capable of full range of motion. The Veteran had an electrodiagnostic evaluation in July 2018, chiefly to examine his injured ankle, but the scope of the examination included the knees. According to these notes, “Inspection and palpation of the bilateral lower extremities reveals no significant misalignment, asymmetry, crepitation, defect, mass, effusion, dislocation, subluxation, instability, laxity or atrophy. Active and passive range of motion of the bilateral lower extremities is intact.” According to a November 2019 primary care note, the Veteran attributed a “forward motion injury” to a “fluidy feeling” in the right knee, which he compared to a “balloon bubbling. . .” The injury occurred when he was hiking the Grand Canyon. According to the physician’s note, there “was swelling of knee, now better. Some feeling of locking when trying to extend full, pain in the back of his knee.” According to a December 2019 orthopedic surgery note, range of motion in the right knee was from zero degrees extension to 110 degrees flexion, with flexion limited by pain. The surgeon wrote that, “He does not have an extensor lag or a flexion contracture. He has 5/5 strength with knee extension. He has negative patellar crepitus and grind. . . Negative Lachman’s. Negative anterior and posterior drawer.” Another surgeon’s note, from January 2020, indicates a range from zero degrees extension to 120 degrees flexion. The Veteran apparently told the surgeon that, “his knee pain has been exactly the same since he was seen here last. It has not gotten any better, but it has not gotten any worse. He does occasionally feel like his knee has been ‘buckling’, but complains mostly of pain going up and down the stairs if he is walking on the balls of his foot.” In August 2020, the Veteran participated in the most recent VA knees examination. The examiner’s report indicates normal initial range of motion test results, with pain during both flexion and extension. The right knee was capable of repetitive use testing and range of motion remained normal after three repetitions. Based on his observation and his interview with the Veteran, the examiner provided estimates of range of motion after repeated use over time and during flare-ups. According to the examiner, range of motion would likely remain normal both after use over time and during flare-ups. The examiner reported on the presence of pain and on range of motion during testing during active and passive motion and in weightbearing and non-weightbearing. The report indicates objective evidence of pain in non-weightbearing but range of motion remained the same as it was during the initial active motion tests – i.e., range of motion remained normal. The examiner wrote that passive range of motion was the same. The August 2020 examiner indicated that muscle strength test results were normal (5/5) with both flexion and extension of the right knee. The results of posterior, medial, and lateral joint stability tests were normal. But there was an abnormal result for the test of anterior instability (Lachman test). The extent of anterior instability was 1+ (0 to 5 millimeters). The examiner also indicated that the Veteran had a meniscal (semilunar cartilage) condition of the right knee, and identified symptoms of meniscal tear, frequent episodes of joint “locking”, joint pain and joint effusion. According to the examiner, the Veteran regularly used a knee brace, but there was no indication in the report, or in the medical records, that the use of the brace was prescribed by a medical provider. Analysis As a preliminary matter, the Board finds that the most recent August 2020 examination report is adequate and complies with the relevant prior remand instructions. The examiner complied with Mitchell and Sharp by provided estimates of the probable range of motion in the Veteran’s service-connected right knee after repeated use over time and during flare-ups. The examiner complied with Correia by assessing range of motion using all of the testing methods required by 38 C.F.R. § 4.59, by indicating the testing methods in which pain was present, and, during the tests in which pain was present, by indicating that range of motion, in degrees of extension and flexion, was the same as the results initially recorded during active motion. Having reviewed the evidence, the Board finds that the Veteran is not eligible for a higher rating for limited flexion of the right knee under DC 5260 or for limited extension under DC 5261. Throughout the appeal period, according to most of the test results provided by the VA examiner and by the Veteran’s treating primary care physicians, orthopedic surgeons, and physical therapists, extension remained normal (zero degrees). The same sources indicate that right knee flexion has always been normal (140 degrees) or close to normal. The October 2014 examiner indicated flexion of 135 degrees and reported that objective evidence of pain did not begin until 125 degrees of flexion. The most severely limited recorded measurement of flexion was 110 degrees, reported in the December 2019 orthopedic surgery note. See also March 2020 VA treatment record (flexion limited to 150 degrees). DC 5260 does not authorize a separate 10 percent rating unless flexion is limited to 45 degrees or less. The Board finds that the previously assigned 10 percent rating for the right knee under 38 C.F.R. § 4.59 is appropriate to compensate the Veteran for both painful flexion and painful extension. VA’s General Counsel has indicated that two ratings under DC 5260 and DC 5261 are appropriate if the range of motion in the relevant knee is simultaneously limited to a compensable degree in both flexion and extension. See VAOGCPREC 9-04 (Sept. 2004). But the Board can find no authorization for simultaneous 10 percent ratings for painful, but not limited, extension and flexion under 38 C.F.R. § 4.59. Such an arrangement is inconsistent with the text of the regulation, which refers to one minimal compensable rating “for the joint.” If the regulation authorized a compensable rating for each painful motion contemplated by “a relevant diagnostic code” then it is likely that such a rating would be authorized. But 38 C.F.R. § 4.45(f) defines the knee as one joint, albeit a major one. Two 10 percent ratings for painful flexion and extension would also be inconsistent with the authorization for a “minimum compensable rating” for the joint because such a rating would consist of two 10 percent ratings – more than the minimum degree of compensation for a service-connected disability authorized by the Rating Schedule. For his right knee, the Veteran was also assigned a 10 percent rating for slight instability under DC 5257. The current effective date for that rating (January 22, 2016) is the date of the VA primary care note which reported “mild subjective medial joint instability. . .” Both the October 2014 and November 2015 examiners administered tests of anterior, posterior, medial, and lateral instability and, during both examinations, the results of all four tests were normal. But medical records and diagnostic tests are not necessarily the only acceptable evidence of instability. Cf. Petitti v. McDonald, 27 Vet. App. 415, 427 (2015). The Veteran told the October 2014 examiner that, during flare-ups, his “knee will catch and feel unstable.” See English v. Wilkie, 30 Vet. App. 347 (2018) (the Court recently held that nothing in Diagnostic Code 5257 provides that objective medical evidence is required or is to be favored over lay evidence in determining whether to assign a rating for lateral instability of the knee). Based on this evidence, the Board finds that the symptoms of the Veteran’s right knee disability most closely approximate slight instability for the entire rating period on appeal. As such, and resolving reasonable doubt in the Veteran’s favor, see 38 C.F.R. § 4.3, the Board will assume that the Veteran’s symptoms of slight instability under DC 5257 were present throughout the entire rating period on appeal. Accordingly, for the appeal period prior to January 22, 2016, a separate 10 percent rating for right knee instability is warranted. The Board next finds that a rating in excess of 10 percent for right knee instability is not warranted for the entire rating period on appeal under the old version of DC 5257 or that his symptoms satisfied the criteria for a 20 percent rating under the amended criteria after February 7, 2021. See Kuzma, 341 F.3d at 1328-29; 85 Fed. Reg. at 76,463. The August 2020 examiner performed four separate tests of joint stability on the right knee (anterior, posterior, medial, and lateral). Only the Lachman test of lateral instability produced an abnormal result and the examiner identified the extent of the instability as 1+ (0 to 5 millimeters) which is the least severe level of instability among the three choices listed in the examination questionnaire. There were also times – for example, the December 2019 orthopedic surgery consultation – after November 2015, in which the medical evidence indicates that the Lachman test result was normal. This evidence is most consistent with the conclusion that, although the Veteran does experience right knee instability, his instability is mild in degree and is not always present. Thus, the evidence does not support a finding that the Veteran is eligible for a 20 percent rating for moderate instability under former DC 5257. As for the revised criteria, whether the knee instability is properly understood as patellar instability or recurrent subluxation, a 20 percent rating requires a prescription from a medical provider for a brace, cane, or a walker. Although the Veteran has used a brace, his medical records do not indicate that any medical provider has prescribed the use of a brace as an aid to ambulation. Having further resolved a doubtful factual question and a doubtful legal question in his favor, the Board will also award a separate 20 percent rating for dislocation of the semilunar cartilage (meniscus) with frequent episodes of “locking’, pain and effusion into the joint under DC 5258. The doubtful factual question is that, although it appears the Veteran’s initial in-service injury involved damage to the meniscus, at least one recent imaging study of the right knee indicates “no meniscal pathology.” But the August 2020 VA examiner’s report includes this quotation from another recent MRI study: “There is truncation of the anterior horn of the medial meniscus, likely attributed to known partial meniscectomy. However, no abnormal signal is identified in the remaining portion of the medial meniscus. The lateral meniscus is intact with no tear.” In spite of reviewing and quoting this report – describing the lateral meniscus as “intact” – the examiner affirmatively answered the question “did the Veteran now have or ever had a meniscal (semilunar cartilage) condition?” When asked to describe current symptoms of this condition, the examiner indicated meniscal tear, frequent episodes of joint “locking”, frequent episodes of joint pain and frequent episodes of joint effusion. It seems that the examiner reconciled the contradictory information in the record, implicitly suggesting that the “truncation of the anterior horn of the medial meniscus” is a form of “dislocation” of the semilunar cartilage for the purpose of DC 5258, even though parts of the meniscus remain intact. The Board has also considered whether a separate rating under DC 5258 in addition to the previously assigned ratings for instability and painful motion would amount to “pyramiding” – the practice of compensating the Veteran more than once for the same manifestations of service-connected disability – in violation of 38 C.F.R. § 4.14. The United States Court of Appeals for Veterans Claims has held that the pyramiding rule does not prohibit, as a matter of law, simultaneous ratings for instability under DC 5257 and for a meniscal condition under DC 5258 or 5259. See Lyles, 29 Vet. App. at 114. The Court further explained that a rating under DC 5257 did not compensate the appellant “for manifestations of knee disability other than recurrent subluxation and lateral instability, such as pain and swelling.” Id. at 116. Part C2 of the Court’s opinion in Lyles suggests that the assignment of a rating under DC 5258 together with a rating for painful motion is a closer question. As noted, DC 5258 expressly identifies pain as one of the symptoms of meniscal disability considered in the criteria. The Court agreed that manifestations of a meniscal disability could also be compensated under a diagnostic code based on limited or painful movement: “Indeed, [38 C.F.R.] § 4.40 recognizes that functional loss ‘may be due to pain’ and § 4.45(f) expressly lists pain on movement and swelling as ‘related considerations’ for evaluating joint disabilities. Although neither regulation explicitly mentions popping, locking, or grinding, to the extent that those manifestations cause ‘disturbances of locomotion’ or ‘interference with sitting, standing[,] and weight-bearing,’ they too are contemplated by § 4.45(f).” Id. 119. In spite of the Court’s acknowledgment that pain, swelling, popping and locking could potentially be compensated under a separate rating for limited extension under DC 5261, the Court found that the Board failed to adequately explain how the appellant’s other ratings compensated him for his meniscal symptoms under the specific facts of case. Id. The more recent memorandum decision of Dees v. Wilkie, No 18-0460, 2019 U.S. App. Vet. LEXIS 1572 (August 30, 2019) confronted the issue in this case more directly. In Dees, the appellant appealed a Board decision denying simultaneous ratings under DC 5258 and for traumatic arthritis based on limited motion. Id. at *13. The Court vacated the Board’s denial of separate ratings, explaining that “Although DC 5258 contemplates ‘pain’ as a symptom that is contemplated by that DC, the Board failed to explain whether, in this veteran’s case, the 20% evaluation under DC 5258 contemplated his painful motion and associated functional limitation and flares, because it noted only ‘manifestations of limited motion including locking as a result of dislocated cartilage.’ R. at 11. The Board was required to account for this evidence and explain why a separate rating for these symptoms was not warranted. See Lyles, 29 Vet. App. at 109, 117-19.” Id. at *16. The medical evidence in this case does not clearly support a finding attributing all of the Veteran’s pain, swelling, and pain on movement to the dislocation of the meniscus as opposed to the other diagnosed aspects of his service-connected right knee disability, such as the defect of the defect of the medial femoral condyle, status post arthroscopy or his post traumatic arthritis. Under these circumstances, the Board will once again resolve reasonable doubt in the Veteran’s favor and assign a separate 20 percent rating under DC 5258. Because the very first VA examination during the appeal period noted a meniscus condition of the right knee, with frequent episodes of joint “locking”, pain, and effusion, the Board will grant this benefit for the entire relevant appeal period (January 17, 2013 to the present). Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record. Romina A. Casadei Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Nye, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.